Presentation Transcript

1. Overview and Examples of Community Involvement with the Planned Care Model

   Wayne Millington, MPA DDT State Consultation Team
2. Background Impetus for the Planned Care Model (PCM) is from the Institute of Medicine’s (IOM) “Quality Chasm” March, 2001 report; an urgent call for change to close the quality gap in healthcare and recommends a redesign of the American health care system. Findings: The outpatient setting is predominant site of health care delivery in the U.S. Americans receive about half of recommended medical care processes (less for persons with diabetes) - - Preventive--54.9% - Acute--53.5% - Chronic--56.1% - Diabetes--45.4% Source for slides #2-3: Institute of Medicine- www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx
3. Background Continued IOM report offered set of performance expectations for the 21st century health care system Suggested an organizing framework around evidence-based practice. HRSA adopted these measures in 1999- Health Disparities Collaboratives- to address health systems change and improved chronic illness management. Robert Wood Johnson Foundation with the MacColl Institute for Healthcare Innovation designed and implemented the Chronic Care Model, using six main components.
4. Intent of the PCM Intended as a team approach to patient care Over-arching model is often called the Chronic Care Model (CCM); it involves a team approach to addressing chronic conditions and contributing risk factors. PCM involves an attempt to implement what is considered ‘evidence-based’ care (i.e., following research and guidelines) v. the typical care that is actually provided.
5. Justification for Use of PCM 133 million Americans live with a chronic condition. This number is projected to increase by more than 1% per year by 2030, resulting in an estimated population of 171 million chronically ill Americans. Almost half of all people with chronic illness have multiple conditions. Managed care and integrated delivery systems are interested in correcting the systems deficits in the current management of diseases such as diabetes, heart disease, depression, asthma, and others. Sources for slides #4 – 15: 1) Johns Hopkins University, Baltimore, MD for The Robert Wood Johnson Foundation (September 2004 Update). "Chronic Conditions: Making the Case for Ongoing Care“; 2) Robert W. Johnson- www.improvingchroniccare.org/index.php
6. Barriers to Effective Chronic Disease Management Rushed practitioners not following established practice guidelines (according to Robert Wood Johnson surveys) Lack of care coordination (within larger health systems and community-level settings) Lack of active follow-up to ensure the best outcomes/case management Patients inadequately trained to manage their illnesses
7. The Chronic/Planned Care Model
8. Six Components of the PCM 1. Self-Management Support 2. Decision Support 3. Delivery System Design 4. Community 5. Healthcare Organization 6. Clinical Information Systems * Evidence suggests that implementing at least one component of the PCM leads to efficacious health outcomes in the long-term.
9. Self-Management Empower and prepare patients to manage their health and health care. Emphasize the patient’s central role in managing their health. Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up. Organize internal and community resources to provide ongoing self-management support to patients (e.g., group visits, health education materials).
10. Decision Support Promote clinical care that is consistent with evidence-based practices and patient preferences. Embed evidence-based guidelines into daily clinical practice (e.g., ADA guidelines, National Heart Lung Blood Institute – NHLBI, etc.). Integrate specialist expertise and primary care. Use proven provider education methods. Share evidence-based guidelines and information with patients to encourage their participation.
11. Delivery System Design Assure the delivery of effective, efficient clinical care and self-management support. Define roles and distribute tasks among team members. Use planned interactions to support evidence-based care. Provide clinical case management services for complex patients. Ensure regular follow-up by the care team. Give care that patients understand and that fits with their cultural background; culturally and linguistically appropriate.
12. Community Mobilize community resources to meet needs of patients. Encourage patients to participate in effective community programs (e.g., PA, nutrition, YMCA primary prevention, health education, etc.). Form partnerships with community organizations to support and develop interventions that fill gaps in needed services. Advocate for policies to improve patient care.
13. Health Care Organization Create a culture, organization and mechanisms that promote safe, high quality care. Visibly support improvement at all levels of the organization, beginning with the senior leader. Promote effective improvement strategies aimed at comprehensive system change. Encourage open and systematic handling of errors and quality problems to improve care. Provide incentives based on quality of care. Develop agreements that facilitate care coordination within and across organizations.
14. Clinical Information Systems Organize patient and population data to facilitate efficient and effective care. Provide timely reminders for providers and patients (i.e., ‘tickler’ systems). Identify relevant subpopulations for proactive care. Facilitate individual patient care planning. Share information with patients and providers to coordinate care. Monitor performance of practice team and care system. Track clinical outcomes within patient population (e.g., ABCs).
15. Six Components of the PCM (Handout) Self-Management Decision Support Delivery System Design Community Organization of Healthcare Clinical Information Systems Set and document Collaborative goals Use of agreed upon guidelines to deliver care Use of the registry to proactively review care Broadly define community and involve them in the team Update Board, staff and community monthly on progress Develop system for data entry and management Follow-up and monitor Collaborative goals Use of registry to provide feedback to team and leaders Cross train staff to expand capability Obtain supplies and services at reduced cost (or free) Senior leader is a member of the team Use database for proactive management Group visits formatted to educate and provide support Use of protocols for referral and communication with specialists Use of promotora programs for outreach, case management, and follow-up Obtain financial support from the community Chronic disease is included in strategic, business, improvement plans Develop database Provide tool to patients to self-manage Concentrate ongoing education based on guidelines Use individual or group planned visits to deliver care Encourage participation in community offered education classes and support groups Outline the business case Assure data integrity Train providers to help patients set Collaborative goals Use of care management conferences to raise patient issues Use standing orders for routine referral and care Raise community awareness through networking and education Spread Care Model to other chronic disease Provide appropriate access to the system Use culturally competent standardized educational materials Provision of training and tools for providers on Collaborative goal setting Bring services together to deliver care Team given autonomy to make changes Provide technical support Use of lay workers to link to communities and as resource to health center community Tap community resources to achieve self-management goals Educate patients about guidelines Identify charts of patients. Community assessment performed to determine strengths and needs Develop a flow sheet for provider/patient interaction and data collection/entry
16. Rationale for PCM Presentation 76% of DPCPs are using a Planned Care/Chronic Care Model approach as their ‘Health Systems’ intervention focus area; most are engaged in self-management support, decision support, and/or clinical information systems. Initial review of DPCP success stories from previous 6 years of grant funding indicates states have been working in this area for years and wish to continue meaningful health system change. CDC has increased emphasis on measurable outcomes, and with many DPCPs working in health systems to impact the ABCs, DDT chose to focus on the PCM as part of its top 3 Quarterly Progress Report priorities.

17. Evaluatingthe Planned Care Model:Strategies & Challenges

    Evaluation Team Division of Diabetes Translation
18. Overall Goals of PCM Improve Clinical care of individuals with chronic diseases Clinical outcomes that impact morbidity and mortality By improving Health systems through implementation of one or more of the PCM’s six component areas
19. Examples of Outcomes

20. Planned Care ModelState Examples

    Vermont DPCP Arizona DPCP Virginia DPCP
21. Self-Management Support In The Planned Care Model Robin Edelman, MS, RD, CDE; DPCP Administrator Self-Management Support Trainer
22. Self-Management vs. Self-Management Support Self-Management Actions and behaviors that patients undertake to care for themselves SM Support What providers do to empower patients and help them develop health behaviors and strategies to live as fully and productively as possible
23. Delivery Systems Redesign for improved self-management support Collaborative approach to care Panel management Planned visits Continuous follow-up Rapid change improvement cycles to test redesign strategies: plan, do, study, act (PDSAs)
24. Self-management Support: Via Coach the Coach: Occurs before, during, and after patient encounters Requires systems changes (redesign) to assist primary care teams in accomplishing care and support Leads to efficiencies in other areas Occurs on the frontline of care in rapid cycle PDSAs Stanford Master Training for Coaches in October 2009 Training in Clinical Microsystems and Self-management support in December 2009 Refresher/brainstorming in March 2010 Project finale in May 2010 Bi-weekly conference calls Site visits
25. Process Improvement Elements of Practice Redesign for Self-Management Support* Start with the patient’s perspective & study current workflow and visits Identify/plan opportunities for improvement Assign practice staff roles & train staff Implement change on a small scale - PDSA Adapt/Adopt changes PDSA repeatedly, expand, and sustain successful changes *facilitated by Coaches - also called Facilitators
26. Implementation of the PCM in Vermont:Setting and Target Audience Primary care practice clinics and collaborative learning sessions Coaches getting trained by project leaders Project leaders and coaches are funded by Vermont Blueprint and the VT DPCP (program administrator’s time) Visit http://newhealthpartnerships.org/ “Improving Care by Engaging Patients”
27. Four Project Leaders – combined skills* Clinical practice administrator skilled in Clinical Microsystems & practice redesign Nurse diabetes educator, former case manager and current facilitator for several practices using Clinical Microsystems to obtain NCQA accreditation Health educator, experienced public health programs administrator & Stanford master trainer The DPCP administrator, dietitian, diabetes educator & Stanford T-trainer * sub-contract for evaluation services
28. How they are using Evaluation Tools: Assessment of Primary Care Resources and Supports for Chronic Disease Self Management (PCRS: adapted from http://improveselfmanagement.org/ ) Primary care patients chart audits DocSite registry panel management …… And What We’re Learning
29. PCRS Process Measures: Patient Support Individualized assessment of patient’s self-management educational needs Patient self-management education Long-term collaborative goal setting Short-term patient directed action planning Problem-solving skills Emotional health Patient involvement in decision making Patient social support Linking to community resources
30. PCRS Process Measures: Organizational Support Continuity of Care Coordination of Referrals Ongoing quality improvement Follow-up on action plans System for documentation of self-management support services Patient input Integration of self-management support into primary care Patient care team (internal to the practice) MD, team & staff self-management educ/training
31. Chart Audit Process Measures: Documentation that: The patient is continuing to work on goals set prior to medical record review There is discussion of patients’ goals The PCP noted patient efforts and success At least 1 referral to a self-management program Follow-through by patient to above referral The PCP reviewed this referral with the patient as a subsequent visit Chart audit/registry outcome measures: A1C, blood pressure, lipids, body weight

32. Overview and Evaluation of the Planned Care Model (PCM)Virginia’s Experience with the Clinical Information System Component

33. 1999-2004 DPCP and CVH Projects worked independently with Virginia’s primary care association and (CCNV) Community Care Network of Virginia using DEMS, CDEMS and PECS
34. 2005-2009 DPCP and HDSP Projects worked collaboratively with Virginia’s PCA using PECS and EMR
35. Participation in Collaborative
36. 2010-2014 DPCP, HDSP and Tobacco Projects work collaboratively with the PCA and CCNV using the EMR
37. 92% of Centers and 63% of Sites are Implementing EMR
38. Clinical Information System Component Evaluation Plan Evaluation Plan that focuses on parallel use of: EMR to track clinical outcome measures at the  short, intermediate and long term outcome stages Surveys (Patient/provider and modified ACIC) to assess system changes for quality improvement at the short, intermediate and long term outcome stage
39. Lessons Learned:DPCP, HDSP Staff Perspective Find technical expertise and statewide reach EMR implementation takes time Determine if data from different EMRs can be aggregated. How will providers access data for quality improvement
40. Lessons Learned:DPCP, HDSP Staff Perspective Find technical expertise and statewide reach EMR implementation takes time Determine if data from different EMRs can be aggregated. How will providers access data for quality improvement Take advantage national push for EMRs
41. Lessons Learned: State Partner (CCNV) Perspective Workflow analysis Physician/provider experience with technology Training and Staff turnover Individuality of health centers Flexibility of EMR product Lack of structured data fields Incomplete Lab interfaces

42. Mt. Graham Continuum of Care Partnership ProjectEvaluation

    Arizona Diabetes Program
43. Mt. Graham Regional Medical Center Safford, AZ Southeastern Corner of Arizona in Graham County Closest Metropolitan Area: Tucson, AZ – 140 miles Closest Hospital of Equivalent Size: Silver City, NM – 100 miles
44. Arizona Dept of Health Services Grant Establish the infrastructure using components of the Planned Care Model for a comprehensive and sustainable diabetes self-management program in partnership with local health care providers and Carondelet Health Network’s Diabetes Care Center in order to offer a continuum of diabetes care. Project placed emphasis on Health Care Organization and Delivery System Design
45. Health Care Organization Develop agreements that facilitate care coordination within and across organizations Nurse Diabetes Educators in primary care offices
46. Delivery System Design Provide an ADA-recognized Diabetes Self-Management Training Program satellite at MGRMC with reimbursement by Medicare and other health plans Host diabetes clinic “one stop” for retinopathy and foot exams, lab work, and MNT Offer a monthly Free Community Survival Class
47. Decision Support Professional Continuing education for health care providers offered by Carondelet Diabetes Education Institute Evidence-based guidelines provided to provider offices and implemented in inpatient and outpatient settings
48. Evaluating the Mt. Graham Project: Summary Description of the Program Overall Intervention Goal: Prevent complications, disabilities, and burden associated with diabetes in Graham County, Arizona Major Components of the Intervention: Establishment of the MGRMS Continuum of Care Program infrastructure Formalization of the MGRMC Diabetes Partnership Provider training including physicians, nurses, and promotores
49. Evaluating the Mt. Graham Project: Creating an Evaluation Plan Process Research Questions and Data Collection: Does Mt. Graham have in place a collaborative and active Diabetes Partnership? Is there a staffed, formalized MGRMC diabetes program infrastructure? Were physicians, nurses, and promotores trained in diabetes curricula? Evaluation Tools: progress reports, policies and procedures manuals, training evaluation tools Sample populations: key project leaders, participating providers
50. Evaluating the Mt. Graham Project: Creating an Evaluation Plan Outcome Research Questions and Data Collection: Did the Mt. Graham Partnership leadership and management improve? Did the Mt. Graham Partnership improve collaboration among partners? Does the Mt. Graham partnership have an effective infrastructure? Does the Mt. Graham partnership have sustainable resources to support it? Evaluation Tool: Tools for Building Clinic-Community Partnerships to Support Chronic Disease Prevention and Control Programs (Robert Wood Johnson) Sample populations: MGRMC Partnership members
51. Evaluating the Mt. Graham Project: Creating an Evaluation Plan Outcome Research Questions and Data Collection: Did the Mt. Graham Partnership improve community linkages around diabetes care? Did the Mt. Graham Partnership improve healthcare delivery system organization? Does the Mt. Graham partnership improve the design of the system providing diabetes care? Did the MGRMC project improve self-management support? Evaluation Tool: Modified Assessment of Chronic Illness Care (MacColl Institute for Healthcare Innovation at Group Health Cooperative) Sample populations: key project leaders
52. Evaluating the Mt. Graham Project: Creating an Evaluation Plan Impact Research Questions and Data Collection: Did the MGRMC project increase organizational support of self-management among PWD? Did the MGRMC project improve and enhance access to diabetes care among PWD? Did the MGRMC project improve clinical outcomes among PWD? Evaluation Tool: Tools for Building Clinic-Community Partnerships to Support Chronic Disease Prevention and Control Programs (RWJ), Clinical indicators, BRFSS Sample populations: key project leaders, clinical records, random sample of Graham County adults
53. Evaluating the Mt. Graham Project: Collecting the Data, Designing Tools Continuum of Care Outcome Evaluation: Assessment of Chronic Illness Care - designed to help systems and provider practices move toward the “state-of-the-art” in managing chronic illness Drawbacks of the tool for our program: Less intuitive scale from 0 to 11 No option for aspects of chronic illness care that were not being addressed in this project No opportunity to provide comments when clarification was required Length and readability of tool
54. Evaluating the Mt. Graham Project: Collecting the Data, Designing Tools Modifications: Health Services Advisory Group simplified the tool previously for the Partners in Quality/Arizona State Diabetes Collaborative More intuitive scale from 1 to 10, including N/A Added general instructions on the implied meaning of each number rating (modeled after the Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) from RWJ) Added space for comments after each response
55. Evaluating the Mt. Graham Project: Evaluation Timeline Timeline: Baseline measure pre-project implementation Interim progress report at mid-point Final survey at project close Results used to identify: Measurable outcomes using an evidence-based tool Level of implementation in specific areas of focus (patient-provider level, team level, or system level change) Next steps for planning purposes
56. Acknowledgements Partners Carondelet Health Network Mt. Graham Regional Medical Center Arizona Diabetes Program Bureau of Tobacco and Chronic Disease Evaluation staff U of A Prevention Research Center
57. Questions? Thank you very much!